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OMT Minute  |   January 2020
High-Velocity, Low-Amplitude Management of Posterior Rib Somatic Dysfunction
Author Notes
  • From the Department of Osteopathic Manual Medicine at Des Moines University College of Osteopathic Medicine in Iowa. Student Doctor Kasten is an Osteopathic Manipulative Medicine Fellow. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Drew D. Lewis, DO, Des Moines University College of Osteopathic Medicine, 3200 Grand Ave, Des Moines, IA 50312-4104. Email: drew.d.lewis@dmu.edu
     
Article Information
Neuromusculoskeletal Disorders
OMT Minute   |   January 2020
High-Velocity, Low-Amplitude Management of Posterior Rib Somatic Dysfunction
The Journal of the American Osteopathic Association, January 2020, Vol. 120, e1-e2. doi:https://doi.org/10.7556/jaoa.2020.013
The Journal of the American Osteopathic Association, January 2020, Vol. 120, e1-e2. doi:https://doi.org/10.7556/jaoa.2020.013
Web of Science® Times Cited: 2
  
High-Velocity, Low-Amplitude Management of Posterior Rib Somatic Dysfunction
eVideo. In this video, HVLA is used to directly address the articular aspect of a posterior rib somatic dysfunction.
Optimal rib mechanics are of vital importance in maintaining scapulothoracic mechanics, shoulder posture, balance in the sympathetic nervous system, venous and lymphatic return, and overall health. Diagnosis and management of rib somatic dysfunction is useful for a multitude of acute and chronic conditions in both hospital and ambulatory settings. For patients who are in the hospital, management of rib somatic dysfunction is important to optimize respiratory and circulatory function and prevent hospital-acquired comorbidities. In the ambulatory setting, management of rib somatic dysfunction addresses many common pain presentations, including interscapular and mid- to upper back pain, as well as head, neck, and upper and lower limb complaints. 
Each rib has a costovertebral joint between the head of the rib and the vertebral bodies. Additionally, each rib has a costotransverse joint between the rib tubercle and transverse process facet. These joints allow for a smooth gliding motion during respiration. The ribs are also sites of extensive myofascial attachment to allow for breathing and other actions of the thorax, head and neck control, and upper limb and trunk motion. Articular or myofascial restrictions of the ribs can therefore directly impede respiratory motion and indirectly cause postural implications for regions adjacent to the thorax. 
Posterior rib somatic dysfunction tends to be more articular in nature and can be the key rib of restricted groups of ribs in inhalation, exhalation, or both.1 Common causes of posterior rib somatic dysfunctions include cough, poor posture, increased kyphosis, poor lifting technique, or excessive physical activity. 
Pain and somatic dysfunction related to posterior ribs commonly results in a protracted scapula with an anterior shoulder posture that leads to dysfunctional scapulothoracic mechanics.2 Dysfunctional scapulothoracic mechanics is frequently implicated in rotator cuff syndromes and other common painful conditions of the shoulder, head, and neck. Therefore, management of posterior rib somatic dysfunction can be significantly beneficial for upper back, neck, and shoulder pain, as well as headaches. 
Rib dysfunction can be a result of, or contribute to, aberrant facilitation of the spinal reflexes. Management of affected regions can therefore help balance the neural and autonomic influences of these conditions. 
Diagnosis of posterior rib somatic dysfunction involves palpating along the posterior thorax and identifying a prominent rib angle that is also tender.1 The seated patient is instructed to cross his or her arms in front of the body to protract the scapula and to slouch or flex forward, which makes the ribs more prominent for palpation. A rib that feels more prominent posteriorly and may be tender to the patient is diagnosed as posterior rib somatic dysfunction. 
The high-velocity low-amplitude (HVLA) technique can be used in patients with posterior rib somatic dysfunction. While an elevated rib strain may also be present, the technique in the video focuses on HVLA to directly address the articular aspect of a posterior rib somatic dysfunction. With the patient in a supine position, the physician stands on the opposite side of the posterior rib. The physician positions the patient's arms across the patient's chest, making sure that the arm on the side of the posterior rib is cephalad. The patient is then rolled toward the physician, and the physician sweeps a hand across the patient's rib cage to find the angle of the dysfunctional rib. The physician places his or her thenar eminence between the transverse process and the rib angle. The patient is rolled back onto the physician's thenar eminence. The physician creates a vector force from his or her abdomen through the patient's elbows to the somatic dysfunction. The physician asks the patient to take a deep breath in. With his or her thenar eminence against the patient's ribcage, the physician flexes the patient past the level of somatic dysfunction. The physician coordinates returning the patient to the table with full exhalation so that the vector force is directly over the dysfunctional rib and the slack in the rib cage is taken up upon the patient's full exhalation. The physician applies an HVLA thrust with the epigastrium toward the involved rib angle. The thrust is felt at the thenar eminence; an articulation may be palpated or heard. The physician reassesses by palpating the involved rib angle after treatment. 
Effective treatment of posterior rib somatic dysfunction with HVLA thrust can reduce pain, improve shoulder posture and scapulothoracic mechanics, balance the sympathetic nervous system, improve venous and lymphatic return, and restore health. 
Acknowledgments
We thank Eric Fishback for his video editing, Megan Ellis, OMS III, for being the patient model in the video, and Gina Lewis, DO, and Erika Kolakowski, OMS V, a fellow in for their contributions in editing. 
References
De Stefano L. Rib cage technique. In: Greenman's Principles of Manual Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:265.
Heinking, KP. Upper extremities. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:640.